The Influence Of Effective Communication, Supervision Of The Head Of The Room, And Documentation Of Nursing Care On Improving Patient Safety In Inpatient Rooms (Systematic Literature Reviews)

Dian Tri Febriana; Achmad Zakaria; Adhitya Chandra Setyawan; Muhammad Zulfikar Asumta

doi:10.31004/joecy.v5i2.3015

Authors

Dian Tri Febriana Darul Ulum Jombang Islamic Boarding School University
Achmad Zakaria Darul Ulum Jombang Islamic Boarding School University
Adhitya Chandra Setyawan Darul Ulum Jombang Islamic Boarding School University
Muhammad Zulfikar Asumta Darul Ulum Jombang Islamic Boarding School University

DOI:

https://doi.org/10.31004/joecy.v5i2.3015

Abstract

This study aims to identify and analyze the influence of effective communication, head nurse supervision, and nursing care documentation on improving patient safety in inpatient rooms through a systematic literature review.

Materials and methods.

This research used the Systematic Literature Review (SLR) method to evaluate how effective communication, head nurse supervision, and accurate nursing documentation contribute to patient safety. Literature was obtained from international databases such as PubMed, ScienceDirect, Scopus, ProQuest, and Google Scholar, covering publications from 2018 to 2024. The article selection process followed a systematic screening of titles, abstracts, full texts, and quality assessment using the Joanna Briggs Institute (JBI) appraisal tools. Data were narratively synthesized under three main themes and adhered to ethical scientific principles, although no direct human subjects were involved.

Results.
The findings show that effective communication, accurate nursing documentation, and consistent supervision from head nurses significantly enhance patient safety in inpatient settings. Clear, structured, and empathetic communication fosters teamwork and improves clinical decision-making. Proper documentation supports continuity of care and minimizes medical errors. Supervision by the head nurse ensures procedural compliance and improves the overall quality of nursing services.

Conclusions.
Effective communication, accurate documentation, and proactive supervision are critical components in establishing a safe and high-quality inpatient care environment. Addressing barriers such as hierarchical culture and lack of training is essential for optimizing patient outcomes and strengthening healthcare team performance.

References

Abakumova, I., Mironenkova, N., & Pronenko, E. (2021). Non-verbal communication in meanings transmission. XIV International Scientific Conference “INTERAGROMASH 2021” Precision Agriculture and Agricultural Machinery Industry, Volume 2, 553–562.

Abd El Rahman, A. I., Ibrahim, M. M., & Diab, G. M. (2021). Quality of Nursing Documentation and its Effect on Continuity of patients’ care. Menoufia Nursing Journal, 6(2), 1–18.

Abudalbouh, L. (2023). Electronic nursing documentation interventions to promote or improve patient safety and/or quality care in an acute setting: Rapid review. Journal of Health Sciences, 7(S1), 2993–3006.

Alshammari, M., Duff, J., & Guilhermino, M. (2019). Barriers to nurse–patient communication in Saudi Arabia: an integrative review. BMC Nursing, 18(1), 61.

Ampudia, M., Beck, T., Beyer, A., Colliard, J.-E., Leonello, A., Maddaloni, A., & Marques-Ibanez, D. (2019). The architecture of supervision.

Asmirajanti, M., Hamid, A. Y. S., & Hariyati, R. T. S. (2019). Nursing care activities based on documentation. BMC Nursing, 18(Suppl 1), 32.

Aswad, F., Lestari, Y., & Yetti, H. (2025). Analysis of Implementation of Effective Communication for Patient Safety by Strengthening Risk Management in the Inpatient Room. Journal La Medihealtico, 6(1), 172–180.

Bjerkan, J., Valderaune, V., & Olsen, R. M. (2021). Patient safety through nursing documentation: Barriers identified by healthcare professionals and students. Frontiers in Computer Science, 3, 624555.

Blease, C., Torous, J., & Hägglund, M. (2020). Does patient access to clinical notes change documentation? Frontiers in Public Health, 8, 577896.

Burgener, A. M. (2020). Enhancing communication to improve patient safety and to increase patient satisfaction. The Health Care Manager, 39(3), 128–132.

Coolen, E., Engbers, R., Draaisma, J., Heinen, M., & Fluit, C. (2020). The use of SBAR as a structured communication tool in the pediatric non-acute care setting: bridge or barrier for interprofessional collaboration? Journal of Interprofessional Care, 1–10.

Efendi, Z., & Adha, D. (2025). Improving Patient Safety through Effective SBAR Communication. Journal of Scientific Research, Education, and Technology (JSRET), 4(3), 1517–1521.

Gittell, J. H., Logan, C., Cronenwett, J., Foster, T. C., Freeman, R., Godfrey, M., & Vidal, D. C. (2020). Impact of relational coordination on staff and patient outcomes in outpatient surgical clinics. Health Care Management Review, 45(1), 12–20.

Höglander, J., Holmström, I. K., Lövenmark, A., Van Dulmen, S., Eide, H., & Sundler, A. J. (2023). Registered nurse–patient communication research: An integrative review for future directions in nursing research. Journal of Advanced Nursing, 79(2), 539–562.

Kubota, M. (2019). What is" Communication"?-Beyond the Shannon & Weaver’s Model. International Journal for Educational Media and Technology, 13(1).

Kulińska, J., Rypicz, Ł., & Zatońska, K. (2022). The impact of effective communication on perceptions of patient Safety—A prospective study in selected Polish hospitals. International Journal of Environmental Research and Public Health, 19(15), 9174.

Kustiati, A., Pohan, V. Y., & Hartiti, T. (2020). Analysis of nursing supervision function in nursing supervision implementation. South East Asia Nursing Research, 2(3), 123–131.

Kwame, A., & Petrucka, P. M. (2021). A literature-based study of patient-centered care and communication in nurse-patient interactions: barriers, facilitators, and the way forward. BMC Nursing, 20(1), 158.

Lambert, B., Keuning, M. C., Jutte, P. C., Diemers, A. D., Nieboer, P., & Huiskes, M. (2025). The Many Faces of Good Operating Room Supervision: Supervisors’ and Residents’ Perspectives After Operating Together. Journal of Surgical Education, 82(2), 103396.

Lotfi, M., Zamanzadeh, V., Valizadeh, L., & Khajehgoodari, M. (2019). Assessment of nurse–patient communication and patient satisfaction from nursing care. Nursing Open, 6(3), 1189–1196.

Manik, M. J., & Callaway, P. (2023). The implementation of Tanner’s Clinical Judgment Model and the Indonesian version of the Lasater Clinical Judgment Rubric in the clinical setting. Applied Nursing Research, 73, 151725.

Mohd Salim, N. A., Roslan, N. S., Hod, R., Zakaria, S. F., & Adam, S. K. (2023). Exploring critical components of physician-patient communication: a qualitative study of lay and professional perspectives. Healthcare, 11(2), 162.

Putri, A. D., & Hidrus, A. (2025). Evaluation of Patient Safety Goals Implementation for Postoperative Inpatient Protection at Bhakti Kartini Hospital in 2023. Journal of Resilient and Sustainability for Health (JRSH), 2(1), 46–54.

Ryan, S., Ward, M., Vaughan, D., Murray, B., Zena, M., O’Connor, T., Nugent, L., & Patton, D. (2019). Do safety briefings improve patient safety in the acute hospital setting? A systematic review. Journal of Advanced Nursing, 75(10), 2085–2098.

Samani, S., & Rattani, S. A. (2023). Fostering patient safety: Importance of nursing documentation. Open Journal of Nursing, 13(7), 411.

Scarlat, C., & Bărar, D.-A. S. (2023). Towards a Transcultural Approach for Inter-Professional Communication in Complex IT Project Teams—Aiming to Avoid Cross-Functional and Cross-Hierarchical Conflicts. Systems, 12(1), 10.

Sharkiya, S. H. (2023). Quality communication can improve patient-centred health outcomes among older patients: a rapid review. BMC Health Services Research, 23(1), 886.

Tajabadi, A., Ahmadi, F., Sadooghi Asl, A., & Vaismoradi, M. (2020). Unsafe nursing documentation: A qualitative content analysis. Nursing Ethics, 27(5), 1213–1224.